A Celebration of Lives Input Form

Name of deceased
First Last
Upload a photo of the deceased
Choose a photo to upload that is under 50MB and is a .png, .gif or .jpg format.
Max. file size: 512 MB.
Birth
Death
About the deceased
In 200 words or less, tell us about your loved one's journey with Primary Immunodeficiency
NOTE: Submission of individuals to the Celebration of Lives webpage will only be completed once verification has taken place.
For Verification
Please fill in the information below to verify the information submitted above.
Name of individual making submission
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Check box for agreement*
- I am authorized to submit the name of the deceased for inclusion on Immunodeficiency Canada's Celebration of Lives website page.

For Verification